NURSING STUDENTS’ LEARNING EXPERIENCES IN CLINICAL SETTINGS:

STRESS, ANXIETY AND COPING

A THESIS PROPOSAL
Presented to the Faculty of Graduate School
Misamis University, Ozamiz City

In Partial Fulfillment of the Requirements for the Degree of

Master in Nursing

JOHN ACE R. JUBAY

OCTOBER 2019
 MISAMIS UNIVERSITY
Ozamiz City
Graduate School

APPROVAL SHEET

In partial fulfillment of the requirements for the degree of Master in Nursing, this thesis entitled,
“Nursing Students’ Learning Experiences in Clinical Setting: Stress, Anxiety and Coping”
is hereby recommended for acceptance and approval.

LLOYD B. RANISES, Ph.D.

Adviser

Approved by the Graduate School Thesis Committee

ELLEN C. QUIRONG, M.I.H. VIRGILIO H. ONGANIZA, D.O.D.T.

Panel Member Panel Member

ATTY. ANTHONY L. AWA

Panel Member

Accepted and Approved in Partial Fulfillment of the Requirements

For the Degree of Master in Nursing
Date: October 2019

VIRGILIO H. ONGANIZA, D.O.D.T.

Chairman, Department of Social Sciences

Dean, College of Arts and Sciences

 ACKNOWLEDGMENTS

This thesis would not have been possible without the help of these following people
whose love, support and guidance have helped us in our venture to finish this paper.

I owe my deepest gratitude first of all to the Almighty God for His grace that sustained
the course of this research, overcame the difficulties, and enlightened the researcher that enabled
to fully understand the study and put all things towards completion of this work.

I would like to show my gratitude to Dr. Lloyd Ranises, our thesis adviser. His
support and guidance have helped us to finish this paper. I like to thank him for his
understanding, leniency and making himself available whenever we need consultations
regarding our thesis. In addition, I am grateful to Dr. Elena Pernia, our thesis proposal
adviser.
It’s an honor for me to thank Atty. Rizalino T. Jose, OIC of DepEd National
Capital Region for the issuance of permit in order for us to conduct survey in selected
NCR schools. I would also like to thank the ten schools for their participation.
I am very grateful to my family: my mother, Ate Cynarra and Joseph for their
love and support. Lastly, I want to show my gratitude to my thesis partner and best
friend, Precious B. Romano. This thesis is the fruit of our hardship, sleepless nights and
worried times. I want to thank you for being an understanding and caring thesis partner. I
am glad to finish this thesis with you. Thank you!
Dedication
ABSTRACT

Nursing Students‟ Learning Experiences in Clinical Settings: Stress, Anxiety and Coping

This qualitative study explored nursing students‟ learning experiences during their

clinical rotations, with a focus on stress, anxiety and coping. The six student participants

were in the last semester of a three-year nursing program in a Montreal CEGEP. Three

students reported this experience to be stressful, two described their experience as very

positive and one described it as average. Despite different perceptions, all of the study

participants identified a variety of stressors. These were classified under four thematic

areas: 1) Learning environment, 2) Preparation for clinical and perception of self, 3)

Effects of stress and anxiety, and 4) Coping skills.

Participants felt that communication and the development of relationships with

nurses and medical staff was difficult and stressful. Therefore, as students, they felt they

did not belong on the team. Although participants described most of their teachers as

approachable, several reported that the constant evaluation process, high and unrealistic

expectations teachers had regarding students‟ knowledge and performance, and lack of

autonomy to practice led to heightened states of stress and anxiety.

Stress did not have an adverse effect on the performance of the clinical skills as

reported by the students, but they acknowledged that it did affect their memory, retention

and thinking process negatively. The study yielded new qualitative data on coping

methods which students use in special situations in the clinical environments: a

combination of emotion-focused and problem-focused coping methods. Emotionfocused methods were

used more often. The findings have implications for improving

iv

learning and teaching practice and the environment of clinical experience for all
concerned: nurse educators, nursing staff and teams, medical and management team and

the students.

Table of Contents

TITLE PAGE i
APPROVAL SHEET ii
ACKNOWLEDBMENTS iii
DEDICATION v
ABSTRACT vi
TABLE OF CONTENTS vii
LIST OF TABLES ix
LIST OF FIGURES x

CHAPTER Page

1 THE PROBLEM AND ITS SCOPE 1

Rationale 1
Theoretical Framework 3
Statement of the Problem 6
Scope and Limitations 7
Significance of the Study 7
Definition of Terms 8

2 REVIEW OF RELATED LITERATURE 12

Related Literature 12
International 12
Local 13
Related Studies 17
International 17
Local 19

3 RESEARCH METHODOLOGY 20
Research Design 20
Locale of the Study 20
Respondents of the Study 22
Data Gathering Procedure 23
Data Analysis Technique/s 24
 4 PRESENTATION, ANALYSIS,
AND INTERPRETATION OF DATA 25

Production of the Emergency Currency Notes Agency

Operations
Areas in the operation
People’s Participation
Problems in the operation
Relevance to local history

5 SUMMARY, MAJOR FINDINGS, IMPLICATIONS,

AND RECOMMENDATIONS 26

Summary
Major Findings
Implications
Recommendations

REFERENCES 27

APPENDIX 30

A Letter Request for the Local Government

of Jimenez for conducting this study 30

B Questionnaires 31

C Transcription of Interviews 33

D Bacarro Printing Shop 34

E Emergency Notes found in the Bacarro

Printing Shop 35

F Interior of the Bacarro House, now Nacion House 36

CURRICULUM VITAE 37
LIST OF TABLES
 LIST OF FIGURES

Figure Page

1 Paradigm on the Production of Emergency Currency

Notes in Jimenez, Misamis Occidental 5

2 Location of Jimenez in the Province of Misamis Occidental,

Northern Mindanao 22
 CHAPTER 1

INTRODUCTION AND PURPOSE

Introduction

My story

The idea to explore the clinical experiences of nursing students came from my

own experiences as a nursing student, then as a nurse and eventually as a nursing

educator. During my undergraduate studies in nursing school I was constantly stressed. I

remember my anxiety before the clinical days. At times it was hard to deal with, so I

occasionally took “mental health days” and called in sick. The main source of my stress

was a feeling of incompetence, being afraid to find myself in a situation that I would not

know how to deal with, and sometimes perceived lack of support from the faculty.

Today, I am in the unique position to see the students in a variety of settings: in the

classroom, in labs and in the clinical areas. It is striking how different some of the

students are in the hospital settings. Many exhibit signs of stress and anxiety while some

adjust easily and seem to cope well with the new challenges.

I wanted to find out what the clinical experiences were like for the students today.

Health care has changed considerably from the time when I was at school. The patients in

the hospitals suffer from a wide array of illnesses, the cases are more complex, the

shortage of nursing staff affects daily care, and the stress of the working nurses is visible.

How does the student deal with all this? As a teacher and a human being I want all my

students to learn in a non-threatening atmosphere. It is obvious that there are a multitude

of factors and variables which may make the learning experience stressful or anxiety

provoking. What are the factors which contribute to their learning and what are the ones

2
which inhibit it? Some of them are not in our control, but many are and this is why I

wanted to identify those factors which as a teacher I could influence

Background of the Problem

In Quebec, nursing education programs are offered at both the college level and at

the university level. Most programs last three years and besides the theoretical

component, each program has a clinical component. A clinical setting, which is most

often a hospital setting, gives the student an opportunity to integrate theory learned in the

classroom into practice. In most of programs, students spend on average two days a week

in a clinical setting under the supervision of a clinical teacher (usually member of the

faculty). During the three year program students are rotated through a variety of settings;

each semester the setting changes and in some semesters it changes twice. Learning takes

place within the social context of the clinical setting, in which students constantly interact

with nurses, doctors, orderlies, patients, patients‟ families, and a multitude of other health

care professionals. Each new placement means the student must socialize into a new

setting, establish relationships with staff while being exposed to new clinical situations,

with different patient populations, and to clinical situations that are acute and can change

quickly. At the same time students‟ clinical performance is continuously being evaluated

by a teacher. All of these experiences have the potential of being stressful and anxiety

provoking.
Rationale for the Study

Most research studies examining stress and anxiety experienced by nursing

students during their clinical rotations are quantitative in nature. Although these studies

identify factors influencing students‟ feeling of stress or anxiety, many are listed under

general categories (i.e. relationship with faculty, relationship with staff), therefore they

do not provide details on which aspects of a particular category are perceived as stressful

or anxiety provoking. There is also very limited research on how nursing students cope

with stressful situations in clinical settings. The rich data from the most recent

qualitative study done by Melincavage (2008) on the subject of stress and anxiety

provides a glimpse into the world of nursing students‟ learning environments and their

perceptions of anxiety in clinical settings. My study complemented Melincavage‟s

research and gave an opportunity for nursing students to share their personal experiences

from clinical rotations, therefore adding to the existing body of literature on this subject.

In addition, I was able to explore students‟ effective and ineffective coping strategies.
Statement of the Research Problem

Canada and the U.S. are facing a nursing shortage. Advances in medical

technology help people to live longer, increasing the aging population requiring medical

and nursing care. Admission to nursing programs has not declined in recent years, but the

number of graduating students may not be enough to provide care to everyone. It is

therefore important that nursing educators not only recruit to nursing schools, but also

provide quality education in an environment conducive to learning which will minimize

attrition. Clinical experience has been linked to high levels of stress and anxiety in

nursing students and the literature shows that there is a link between the nursing student

attrition and the stress related to the clinical experience (Deary, Watson, & Hogston,

2003; Lindop, 1989; Morgan, 2001). Stress related to clinical rotations has also been

shown to increase nursing student absenteeism (Timmins & Kaliszer, 2002). Stress and

high levels of anxiety also negatively affect learning and student performance in clinical

settings. This is discussed in the review of the literature in Chapter Two.

There is a multitude of factors which have been linked to students‟ experiences of

stress and anxiety in clinical setting: a) the interpersonal relationships with health care

professionals; b) constant observation and evaluation by teachers; c) perceptions of nonsupportive,

threatening faculty; d) ineffective teaching skills of the nursing educator; e)

unrealistic expectations by staff and teachers; f) fear of making a mistake or harming a

patient; g) lacking the clinical knowledge to accomplish a task; h) feeling of inadequacy;

and i) unfamiliarity with the clinical setting, among others. Providing clinical experiences

within a non threatening setting is therefore essential to student learning. The goal of this

research was to describe the realities of students‟ clinical experiences and to develop a

deeper understanding of the stressors facing students during their clinical learning. The
results of the study will hopefully sensitize nursing educators and nurses working with

nursing students to the challenges students are facing. One reason for undertaking this

study was to identify stress-provoking factors in the clinical environment which teachers

might influence, so as to optimize the learning environment. The study also examined the

coping methods used by nursing students. I hope the results of this study will encourage

nursing educators to examine their teaching methods and approaches to students in order

to better support the students in their learning in a stable environment conducive to

learning.